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Please complete this confidential form. Our clinician will review and respond shortly.

Urinary Tract Infection Consultation

First Name

Last Name

Are you experiencing a burning sensation when urinating?

Is there blood in your urine?

Do you need to urinate frequently or urgently?

Do you feel pain in your lower abdomen or back?

Have you had a UTI before?

Are you currently pregnant or breastfeeding?

Are you experiencing vomiting or nausea?

Have you developed a fever/high temperature?

Are you experiencing flank/back pain?

Do you have vaginal discharge or itching?

Have you had 2 or more UTIs in the last 6 months?

Do you have known kidney problems or catheter?

Optional Message

You can write any other symptoms or more details in this box if you wish

If you answered ‘Yes’ to any of the above questions above, you may need an in-person assessment. Please contact your GP or NHS 111. We may not be able to offer treatment safely based on your answers.

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